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ENROLLMENT/CHANGE FORM - CA FOR GROUP USE ONLY
Delta Dental of California Group No. Division State
CA
Small Business Program Effective Date Hire Date
Select a Plan:  PPO OR  DeltaCare® USA 1
Delta Dental of California Delta Dental of California
VERY IMPORTANT - Please Print Legibly Name of Employer
Enrollee/Change Information Change Dental Plan*  Add/Term/Change Due to Qualifying Event
 New Enrollment  Address Change  SSN/Enrollee ID Number Correction or  Open Enrollment
previous ID under which benefits are received  PPO – Cancel
T
 Add/Delete Dependent  erminate Enrollee Coverage Enrollee Classification
 DeltaCare USA - Cancel
 Marital Status Change  Change Dental Plans*
 Full-Time  Hourly  Certified
*Enrollees can change plans only during open enrollment or due to a qualifying status change.
 Retired  Salaried  Classified
Primary Enrollee Information  Other ___________________________
Social Security Number Date of Birth Gender Marital Status

xxx-xx-xxx  Male  Female  Single  Married COBRA (if applicable)
First Name Last Name Middle
John  Termination
Mailing Address (Street) City State Zip  Reduction in Hours
Buena Park
 Divorce/Legal Separation**
E-mail Address (internal use only) Phone Number Phone Type
 Cell  Work  Home  Widowed/Surviving Dependent**
Network Facility Name Network Facility Number  Dependent Child No Longer Eligible**

Name of Other Dental Carrier Policy Holder Name (first/last) Date of Birth Indicate qualifying date: ___________________
**If a dependent is enrolling under his/her social
Effective Date of Other Policy Policy Holder Street Address City State Zip security number, the SSN currently enrolled
under must be provided.
Dependent Information

Relationship Dependent First Name (Last only if different from enrollee) Add / Term Date of Birth Male / Female Disabled*** Network Facility Number‡
Spouse/Partner     
Dependent     
Dependent     
Dependent     
Please attach a separate sheet for additional dependent information. All dependents listed will be considered enrolled. ***Additional documentation will be required for disabled status. ‡Maximum of three facilities
per family.

 I authorize any payroll deduction that may be required towards the cost of this coverage. I certify that the above information is true and correct to the best of my knowledge.
I understand that changes can only be made during the annual open enrollment period unless I experience a qualifying family status change, in which case the change must be
consistent with that event, or as may otherwise be provided by the group contract.

 I decline coverage at this time.
Signature of Enrollee ___________________________________________________________________________ Date __________________________________________________
1
DeltaCare USA is our closed network plan that features set copayments, no annual deductibles and no maximums for covered benefits. Enrollees must select a primary care dentist in the DeltaCare USA network
from whom they receive treatment.
Form 3460 CA SBP #96082CA 2-16